By Jennifer Hayashi and Bruce Leff

As the number of older Americans living with chronic illness and disability grows over the coming decades, the need for focused, effective preventive and acute care will also increase. There are now more than 40 million people in the United States ages 65 years or older, and 37 percent of this group are reported to have severe disability, with 16 percent requiring some type of assistance (Greenberg, 2010).

Most elders want to remain in their own homes to age in place rather than relocate to facilities with on-site nursing and medical personnel, although acute and repeated exacerbations of chronic illness may temporarily require intensive medical monitoring and intervention. Ideally, some or all of this care will be provided at home, preventing institutionalization.

The term homecare encompasses an array of home-based services provided by a variety of personnel and funded by many payers. Handson personal assistance provided by informal caregivers or paid aides, while essential to keeping functionally impaired older adults at home, is beyond the scope of this discussion. This article instead addresses medically oriented home- and community-based services (HCBS), concentrating on home-visit programs by healthcare providers.

Models of Medical HCBS

Medical house calls are defined as home visits for medical evaluation and management, as part of ongoing primary care, episodic acute care, and post-acute convalescence or rehabilitation. We will outline models, funding, and effectiveness for house calls by physicians, nurse practitioners, or physician assistants, alone or as part of interdisciplinary teams; and we will describe Independence at Home, an important emerging model that synthesizes existing evidence and aims to reduce cost, improve quality, and promote patient-centered care.

Several models exist for medical house calls, with varying levels of effectiveness. Some studies demonstrate increased patient, caregiver, and physician satisfaction, while others show decreased Medicare costs, hospital use, or nursing home placement. Still others show improved satisfaction associated with increased cost. Appropriate targeting, assessment, and follow-up, plus interdisciplinary approaches to medical, functional, and social conditions are consistently associated with improved processes or patient outcomes (Kao et al., 2009).

Despite differences in types of interventions and evidence, it is useful to break medical house calls into two groups: primary care, which includes transitions to and from acute care; andacute care, or Hospital at Home. These two groups overlap depending upon local circumstances, such as availability of providers and structure of practice, but the general construct provides a framework for understanding the services provided and their potential impact on outcomes.

The primary care model

Medical house calls may complement office visits for older adults with chronic conditions that are hard to manage in the office, or with occasional exacerbations limiting their ability to get to scheduled office visits. Or they may serve as the main source of primary care for patients unable to attend appointments because of physical, cognitive, or psychiatric impairment. A landmark study of 1993 Medicare claims data said most house calls are made by primary care physicians (internists, family practitioners, general practitioners, and geriatricians), with only 8 percent attributed to physicians in other specialties (Meyer and Gibbons, 1997).

Although house calls still represent less than 1 percent of all outpatient medical services billed to Medicare, the number of these visits has increased steadily over the past decade. More recently, a review of Medicare data from 1998 to 2003 showed that the total number of house calls increased by 43 percent, with more than 50 percent of these visits made by primary care physicians (Landers et al., 2005).

By definition, medical house-call programs include at least one medical provider such as a physician, nurse practitioner, or physician assistant. At one end of this medical providerbased practice spectrum is the solo private practitioner who occasionally makes a house call—typically to a patient at the end of life with whom he or she has a long-standing relationship—to manage symptoms or provide emotional support. At the other end is the large multistate corporation, which has hundreds of individual house-call providers and integrated laboratory or radiology services. The capacity of such house-call programs depends upon staffing, geography, and population density.

Although the medical literature of the past thirty years is peppered with occasional essays or reports describing physician or patient satisfaction with individual house calls, there is a relative dearth of data on the effectiveness of either lone practitioner visits or large corporation programs. Evidence for the large practice model exists in business literature, which chronicles the growth of this model as an industry.

For example, Care Level Management provided medical house calls and care coordination in consultation with patients’ primary care providers as part of a Medicare demonstration project targeting high-cost beneficiaries from 2001 to 2007. In 2008, it was acquired by Inspiris LLC to augment Inspiris’ medical care and care management services for high-cost Medicare and Medicaid patients. Reports from Inspiris, which focuses on physician house-call services for Medicare and Medicare Advantage patients, show that hospital admissions, re-admissions, emergency department visits, skilled nursing facility days, prescription medications per patient, and total costs are significantly reduced by their services, while patient satisfaction and health-plan margins increase.

One internal study of 400 “special needs plan” patients (those having chronic disease, functional disability, and high expenditures) and 400 matched controls demonstrated a 63 percent reduction in Medicare hospital admissions in the first seven months, prompting the plan to terminate the study and apply the Inspiris care model to all 800 patients. This success led to Inspiris’ recent acquisition by United Health Care, a branch of the largest health insurance company in the United States (Coleman, 2011a; Coleman, 2011b; Inspiris LLC, n.d.).

The teaching hospital model

Academic house-call practices subsidized by hospitals with teaching programs typically fall somewhere between the two ends of the spectrum described above, with a small cadre of faculty dedicated to educating learners, while providing patient care to a limited panel of patients in the hospital’s immediate geographic area.

A striking exception is the Visiting Doctors Program at the Mount Sinai School of Medicine in Manhattan, with fourteen physicians, four social workers, and four nurses serving more than a thousand patients annually. This thriving group has published data describing their program’s financial contribution to the sponsoring hospital through in-patient admissions and outpatient visits, although the fiscal impact on the healthcare system beyond the hospital is not addressed.

Nursing and social work services are funded through the program budget and are not reimbursed by Medicare. Although direct billing for medical home visits covers only about 24 percent of the program’s cost, the remainder is supported by philanthropy (8 percent), the affiliated medical school (10 percent), and the hospital (58 percent) (Desai, Smith, and Boal, 2008).

The interdisciplinary team model

As noted above, targeting high-cost, frail older patients who would likely otherwise transition frequently between acute-care hospitals and post-acute facilities is key to the financial sustainability of house-call practices. Another important component of many successful models is an integrated interdisciplinary team that can simultaneously address medical, functional, and social problems. Interdisciplinary teams of medical providers, social workers, pharmacists, therapists, and other professionals have long provided medical house calls and home-based primary care (HBPC) through the Veterans Administration (VA) health system.

The unique federal funding of VA HBPC makes it difficult to compare its results to fee-for-service or capitated health systems. But studies of HBPC demonstrate improved healthrelated quality of life and satisfaction among patients and caregivers, reduced length of hospital or nursing home stays, and, as expected, increased outpatient visits and homecare visits, with a 24 percent reduction in total VA costs for HBPC patients (Edes and Kendall, 2005). Among veterans in HBPC who were also Medicare patients, combined VA plus Medicare hospital admissions were reduced 25 percent, and hospital days were reduced 36 percent.

Enrollment in VA HBPC was associated with a net reduction of 10.2 percent in Medicare costs, and a net total reduction of 13.4 percent in combined VA plus Medicare costs, after accounting for the added costs of the HBPC intervention (Kinosian and Edes, 2010). However, these results may not fully apply to settings outside the VA, because funding mechanisms are substantially different for the VA compared with Medicare or commercial insurance. And all team members, including medical providers, are salaried by the VA.

Community collaboration models

Other notable models of team-based house-call practice rely on mutually beneficial collaboration with community partners. For example, a Philadelphia program named EPAC (Elder Partnership for All-Inclusive Care) pairs a medical house-calls practice (that uses a physician and nurse practitioner duo) with the local, community-based long-term-care provider and the area agency on aging. It coordinates medical care, social work, informal caregiving, and paid services such as transportation, medical equipment, home health aides, and adult medical daycare for dually eligible patients. When compared with Medicaid waiver HCBS control patients, EPAC patients had 23 percent lower Medicaid costs largely from 76 percent fewer nursing home months over the span of five years (Kinosian et al., 2011).

Another innovative approach to team-based house calls is the Geriatric Resources for the Assessment and Care of Elders (GRACE) program at Indiana University. In this model, a geriatrics nurse practitioner and social worker make house calls and collaborate with an office-based primary care physician and geriatrics interdisciplinary team to provide integrated home-based care management. GRACE patients showed a reduced rate of emergency department visits and hospital admissions. Costs outside the health system were not evaluated, including home healthcare, durable medical equipment, nursing home care, and existing community-based interventions, such as exercise groups. In this high-risk group, additional analyses demonstrate a net cost neutrality over two years of intervention, followed by net decreases in the year following the intervention, suggesting that intensive primary-care interventions targeted to high-cost patients improve quality and satisfaction without increasing cost to the health system (Counsell et al., 2007; Counsell et al., 2009).

Hospital at Home

A logical extension of providing primary care house calls, when the medical need arises, is providing acute hospital-level care in the home. This is the Hospital at Home (HaH) model of care. The main rationale for HaH care is that the traditional acute hospital environment is unsafe for many patients and unnecessarily expensive. The seminal 2000 report from the Institute of Medicine (IOM), To Err is Human, Building a Safer Health Care System, highlighted the notion that healthcare quality and patient safety are significant concerns in the hospital (Kohn, Corrigan, and Donaldson, 2000).

Iatrogenic events occur commonly in the hospital. The IOM estimated that at least 44,000 people die in U.S. hospitals each year from medical mistakes, at a cost of between $37 and $50 billion. Older adults commonly experience debilitating complications such as delirium, functional decline, pressure sores, and nosocomial infections. Hospital discharge and the transition from hospital to home are especially fraught with difficulties, as evidenced by the remarkably high rates of hospital re-admission among Medicare beneficiaries.

Hospital at Home provides services, therapies, and technologies usually associated with acute inpatient care, but in the home setting. There are a variety of such care models—this article focuses on those substituting for inpatient hospital admission. These models treat acute conditions in the home, providing treatment that requires hospital-type technologies or hospitallevel care; substantial physician and nurse input with full-time clinical coverage; care coordinated in a way similar to an inpatient hospital ward; and ancillary pharmaceutical, laboratory, and basic radiology services.

A wide range of conditions has been treated in HaH, all of which occur often and account for a significant proportion of hospitalizations. These conditions can be diagnosed in a straightforward manner and treated safely, efficiently, and effectively in the home. Such conditions include community-acquired pneumonia, exacerbations of chronic obstructive pulmonary disease or congestive heart failure, cellulitis, deep venous thrombosis, pulmonary embolism, volume depletion, dehydration, urinary tract infection, and urosepsis, among others. In these models, eligible patients are identified in the hospital emergency department and offered the option of HaH care.

There have been a number of well-conducted studies of substitutive HaH reported in the literature. Many have been randomized controlled trials conducted in countries with singlepayer systems. In such systems, the economic incentives to provide HaH care are aligned. A recent Cochrane meta-analysis examined ten randomized controlled trials of substitutive HaH care and found that patients receiving HaH care reported higher satisfaction with care than those receiving inpatient care, and that HaH care was less expensive than traditional acute inpatient care. Remarkably, there was a 38 percent reduction in the risk of death at six months for HaH patients compared with traditional acute inpatients (Shepperd et al., 2009).

In the United States, investigators at Johns Hopkins led the work on HaH, and developed a substitutive HaH model with a robust physician component. The research model focused on treating patients with pneumonia, chronic heart failure, chronic obstructive pulmonary disease, and cellulitis. A national multisite study of the Hopkins model was conducted in Medicare managed care and the VA health systems and demonstrated that HaH care was feasible and efficacious, providing hospital-level care at home that met standard disease-specific quality metrics.

Compared with patients treated in the acute hospital, those treated in HaH suffered fewer clinical complications, including use of sedative medication, chemical restraints, and incident delirium. Patient and family member satisfaction was higher. Although patients were not required to have a caregiver (30 percent lived alone), caregiver stress was lower. The HaH patients improved in the ability to perform instrumental activities of daily living compared with usual care patients. And the average amount paid for HaH patients was lower, the savings resulting from reduced use of laboratory and high-tech procedures (Leff et al., 2005).

Over the past several years, the Hopkins group has focused on disseminating HaH into the U.S. healthcare system. Several additional VA medical centers have adopted the model, as has Presbyterian Health Systems in Albuquerque, New Mexico, an integrated delivery system that uses HaH for Medicare Advantage patients. Most recently, the commercial entity Clinically Home has developed and piloted a more scalable version of the Hopkins HaH model. This model provides physician visits via two-way, biometrically enhanced telemedicine visits, with nurse practitioners and nurses making visits in the home, admitting patients for a thirty-five-day admission so as to better manage the post-acute transition, and a systematic approach to reducing variations in care. Unfortunately, there are substantial payment barriers in fee-for-service Medicare. Recent initiatives such as bundled payments demonstration programs promulgated by the Centers for Medicare & Medicaid Services (CMS) Innovation Center may help reduce such barriers to HaH implementation in Medicare.

Independence at Home: Culmination of the Evidence

Finally, an important emerging model of medical house calls incorporates the key principles of timely and responsive, patient-centered care targeted at high-cost users to reduce costs while increasing quality and satisfaction. These principles, as demonstrated in the studies and successful practices noted above, culminated in the Independence at Home (IAH) Act, section 3024 of the Patient Protection and Affordable Care Act of 2010. The IAH Act mandates that CMS perform a demonstration study of the medical house-call model with a novel payment methodology representing a major shift from standard Medicare reimbursement.

The target population for the IAH demonstration is the most frail, medically complex older adults that constitute the highest cost segment of the Medicare population. Financial incentives are redirected from office-based specialists to mobile teams that must demonstrate improved outcomes for these patients,
coordinating care across different settings, including hospitals and nursing homes. Eachmul ti-disciplinary team of medical providers, social workers, and office support staff works closely with existing community providers of pharmacy, medical equipment, home nursing, rehabilitation, home health aides, and hospice to organize and deliver appropriate care and supplies to patients when and where they need them. Effective, reliable technology promoting efficient communication of critical health information among providers and facilities is an essential part of the IAH team’s infrastructure, as is around-the-clock access to skilled telephone triage and urgent visits (as needed) to prevent unnecessary trips to the emergency room and hospital admissions.

In the current political and fiscal climate, many entities could benefit by sponsoring IAH teams, including hospitals, health plans, physician groups, homecare agencies, long-term-care facilities, and accountable care organizations. Individual physicians, nurse practitioners, or multi-disciplinary teams with experience providing in-home primary care to patients with multiple chronic illnesses may participate in the IAH demonstration. Individual practices may also form a geographic consortium to participate in IAH as a single entity. Each participating practice or entity must provide services to an average of at least 200 eligible beneficiaries during each year of the demonstration, and must be available daily and around the clock to provide care. They must also utilize electronic health information systems, mobile medical technology, and remote monitoring systems. They are required to provide data on multiple quality measures, and in return will receive incentive payments and share in Medicare savings. Complete details of practice and beneficiary eligibility criteria are beyond the scope of this review, but are available on the CMS website.

The IAH teams will provide coordinated, home-based care to Medicare beneficiaries with multiple chronic illnesses, functional disability, and demonstrated high healthcare costs; show a minimum of 5 percent annual savings for Medicare, compared with predicted costs for the target population; share in savings with Medicare (beyond this first 5 percent) to use for program development, including technology or other clinical services; meet three minimum performance standards (patient and family satisfaction, good clinical outcomes, and the aforesaid 5 percent savings); preserve existing Medicare coverage; and be completely voluntary.

The “shared savings” payment model limits the financial risk to Medicare, and gives providers motivation to select high-cost patients who have the greatest potential for savings. At the same time, these highly skilled interdisciplinary teams will provide our neediest, most medically vulnerable patients with safe, effective, highquality, and timely care centered on the patient at home (DeJonge, Taler, and Boling, 2009).

Medical House Calls: An Alternative to Current Practice

Economists, scientists, and policy makers generally agree that the current hospitalcentered healthcare delivery and payment system is not sustainable in the face of the burgeoning population of older adults with chronic complex multimorbidity. Medical house calls, including hospital-level care at home, are an essential component of primary and acute care for these patients, and have been shown to improve outcomes and decrease costs. Fortunately, these patients are the most likely to benefit from intensive outpatient management and coordination of care over time, performed by experienced interdisciplinary teams versed in geriatric principles and practice. These home-based, medical primary-care programs are only rarely well integrated with existing HCBS (as in the case of the EPAC model), and otherwise depend on institutional investment or private payment arrangements. Future research, including evaluation of the IAH demonstration project, should identify more effective practices that maybe rep licable on a national level.

References

Administration on Aging. 2010. A Profile of Older Americans: 2010. Washington DC: U.S. Department of Health and Human Services.

Kinosian, B., and Edes, T. 2010. “Home Based Primary Care for Frail Homebound Veterans as a Model for Independence at Home.” Journal of the American Geriatrics Society 58: S116.

Kinosian, B., et al. 2011. “5-Year Medicaid Cost Savings from Integrating Home and Community Based Services with a Housecall Practice: Elder Partnership for All-Inclusive Care (EPAC).” Journal of the American Geriatrics Society 59: S6.

Jennifer Hayashi, M.D., is assistant professor of medicine at Johns Hopkins University School of Medicine in Baltimore, Maryland. Bruce Leff, M.D., is professor of medicine at Johns Hopkins University School of Medicine.

Editor’s Note: This article is taken from the Spring 2012 issue of ASA’s quarterly journal, Generations, an issue devoted to the topic “30 Years of HCBS: Moving Care Closer to Home.” ASA members receive Generations as a membership benefit; non-members may purchase subscriptions or single copies of issues at our online store. Full digital access to current and back issues of Generations is also available to ASA members and Generations subscribers at Ingenta Connect. For details, click here.

Acknowledgement: Hospital at Home is a United States registered service mark.

Note from the Authors: Disclosure from Dr. Leff: Under agreements between the Johns Hopkins University and Mobile Doctors 24/7 International, the University is entitled to fees for licensing and consulting services related to the HaH care model. Under institutional consulting agreements between the Johns Hopkins University, the Johns Hopkins Health System, and Clinically Home, LLC, the University and Health System are entitled to fees for consulting services related to the HaH care model. The terms of the above arrangements are managed by the Johns Hopkins University in accordance with its conflict-of-interest policies. In addition, Dr. Leff is the president of the American Academy of Home Care Physicians volunteer).

Dr. Hayashi is supported by the Donald W. Reynolds Foundation and the John A. Hartford Foundation